Structural heart disease Flashcards
what are structural heart diseases and what are the types
Defects effective valves and chambers of the heart
1) congenital
2) later in life
what are the congenital structural heart diseases
atrial septal defects ventricular septal defect coarctation of aorta patent foramen ovale patent ductus arteriosus tetralogy of Fallot
what is the pathology of ventricular septal defect? Symptoms? treatments?
Ventricular septal defect : walls between 2 ventricles fails to develop normally → hole in the wall → mixing of blood in L and R ventricles
Symptoms: poor weight gain , decreased appetite, palpitations
Sometimes the hole will close as the child grows
Correction : open heart surgery / cardiac catheterisation
what is the tetralogy of fellow and how is it treated
Tetralogy of fellow ( 4 diseases together )
Ventricular septal defect
Pulmonary stenosis ( pulmonary trunk is narrow
Widening of aortic wall ( allows back flow of blood from ventricle to aorta
Right ventricle hypertrophy ( thickening of right ventricle wall)
Treatment: surgery
what is atrial septal defect
Atrial septal defect : hole in the wall between the 2 atria due to abnormal development
what is coaction of the aorta
Coarctation of aorta : narrowing of wall of the artery → means ventricle must work harder to push blood → thickening of ventricle → heart failure
what are the 2 types of structural valvular defects
These can be divided into 2
stenotic lesions: narrowing
Hardening of the valve reduces the responsiveness to ventricular systolic pressure, thus during ventricular contraction a greater contractile force is required to force the valve to open
regurgitation lesions: dilations
left sided valvular lesions are more clinically significant: mitral stenosis and aortic stenosis
what is aortic stenosis? what is it’s pathophysiology and complications
narrowing of aortic valve
Pathology
mechanical stress ( ie abnormal blood flow) damages endocardium leading to proximal fibrosis and calcification;
valvular endocardium is damaged which initiates an inflammatory process leading to calcium deposition + fibrosis , limiting leaflet mobility → stenosis + less systemic blood flow
In Rheumatic disease : autoimmune inflammatory reaction triggered by prior strep infection that targets valvular endothelium → inflammation + calcification
Complications
Long-standing pressure overload → left ventricular hypertrophy (LVH).
Ventricle maintains normal wall stress (afterload) despite the pressure overload produced by stenosis
As the stenosis worsens, the adaptive mechanism ( LVH) fails and left ventricular wall stress increases.
Systolic function declines as wall stress increases, with resultant systolic heart failure.
what are the causes and risk factors of aortic stenosis
Risk factors : Hypertension LDL Smoking High C peptide Congenital bicuspid valves CKD ( chronic kidney disease) Due to more infection Radiotherapy Due to cancer Older age Due to calcification
Causes: Rheumatic heart disease Most common cause in developing countries Congenital heart disease Calcium build up
Preceded by aortic sclerosis ( aortic valve thickening w/o flow limitation)
what is the presentation of someone with AS
History and presentation Exertional dyspnoea and fatigue Chest pain Shrill Ejection systolic murmur (≥3/6 is present with a crescendo-decrescendo pattern that peaks in mid-systole and radiates to the carotid) Confirmed by echocardiography ( look for LV hypertrophy and thickening) H/O ( history of) Rheumatic fever high lipoprotein high LDL, CKD age >65
what is the management for AS
Management
(Aortic Valve replacement) (AVR)
The primary treatment of symptomatic AS
Asymptomatic patients with severe AS who have an LVEF <50% or who are undergoing other cardiac surgery.
AVR may be considered in asymptomatic patients with very severe AS or severe AS with rapid progression, an abnormal exercise test, or elevated serum B-type natriuretic peptide (BNP) levels
Medications Balloon aortic valvuloplasty Antihypertensive ACE inhibitors Statins
what are investigations for aortic stenosis
Investigations : ECG ( for regurgitation only) Transthoracic echocardiography Chest x ray ( for LV hypertrophy) Cardiac catheterisation Cardiac MRI / CT scan
what is mitral stenosis? what is it’s pathophysiology and complications
structural deformity of mitral valve reducing left ventricular inflow
Pathophysiology
Obstruction to left ventricular inflow at the level of mitral valve due to structural abnormality of the mitral valve
Acute insult lead to formation of multiple foci + infiltrated in the edno + myocardium along walls of valves
With passage of time → thickens → calcified → stenosis
Complications
Initially moderate exercise or tachycardia → exertional dyspnoea due to increased left atrial pressure
Severe mitral stenosis → increase in left atrial pressure
Lead to transudation of fluid into the lung interstitium
Leads to dyspnoea at rest or exertion
Pulmonary hypertension may develop as the result of it
The restricted orifice limits filling of left ventricle limiting cardiac output → can lead to right heart failure
Hemoptysis if bronchial vein rupture
what are the causes and risk factors of mitral stenosis
Causes: Rheumatic fever Main cause in developing countries Typically disease occurs decades after infection Carcinoid syndrome Ergot / serotonergic drugs SLE Mitral annular calcification due to aging Amyloid Rheumatoid arthritis Whipple disease Congenital deformity
What is the presentation of someone with mitral stenosis
Presentation: H/0 of Rheumatic fever Dyspnoea orthopnoea Diastolic murmur Loud P2 Neck vein distention Hemoptysis 40-50 years age
what is the management of mitral stenosis
Management
Progressive asymptomatic
No therapy required
Severe asymptomatic
no therapy generally required adjuvant balloon valvotomy
Severe symptomatic
diuretic, balloon valvotomy, valve replacement & repair adjunct b blockers
what are the investigations of mitral stenosis
Investigations ECG Transthoracic echocardiography Chest X ray Cardiac catheterisation Cardiac MRI/CT Scan
what is aortic regurgitation ? pathology ? Complications?
diastolic leakage of blood from aorta → left ventricle
Pathologies
Incompetence of valve leaflets due to:
Intrinsic valve disease
Dilation of aortic root
Can be :
Chronic : → fulminate into congestive cardiac failure
Acute → medical emergency presenting with sudden onset of pulmonary oedema and hypotension or cardiogenic shock
Complications Acute AR : Increase blood volume in LV during systole LV end diastolic pressure increases increase in pulmonary venous pressure dyspnea and pulmonary oedema heart failure cardiogenic shock
Chronic AR
gradually increase in LV volume
LV enlargement and eccentric hypertrophy
Early stages: Ejection fraction normal or slightly increase
After some time: Ejection fraction falls and LV end systolic volume rises
Eventually LV dyspnoea lower coronary perfusion ischemia, necrosis and apoptosis → heart failure
how does rheumatic fever effect the heart
antibodies against rheumatic fever have a similar shape to heart muscle antigens and so will bind
how does infective endocarditis cause heart disease
Causes vegetations of valve cusps leading to inadequate closure and leads to rupture of leaflets/paravalvular leaks
What are the causes and risk factors of aortic regurgitation
Congenital + acquired
Rheumatic heart disease / rheumatic fever (acute + chronic AR)
Infective endocarditis (Acute AR ) ( Causes vegetations of valve cusps leading to inadequate closure and leads to rupture of leaflets/paravalvular leaks.)
Aortic valve stenosis
Congenital heart defects
bicuspid aortic valves (chronic AR)
Chest trauma ( cause tear in aorta)
Aortic root dilation : Connective tissue disease / collagen vascular diseases marfan syndrome Idiopathic Ankylosing spondylitis Traumatic
Risk factors
high bp, systemic hypertension
what is the presentation of aortic regurgitation
Acute AR Cardiogenic shock Tachycardia Cyanosis Pulmonary edema Austin flint murmur Chronic AR Wide pulse pressure Corrigan (wide hammer pulse) Aka forceful pulse that suddenly collapses Pistol shot pulse (Traube sign) Loud cracking sound heard over the stethoscope due to dilation and collapse of aorta
